is a Specialist in , . practices all healthcare services and medical treatments related to Specialist. The NPI Number for is 1083764195. The last update date is .
's current location address is , , . You can contact this provider via phone number . The mailing address for is , , . To know further, please read the information below!
Provider Profile Detail
| Provider Name | |
|---|---|
| Address | , , |
| Phone Number | |
| Fax Number | |
| Sole Proprietor | -- |
| Credentials | -- |
NPI Number Detail
| NPI Number | 1083764195 |
|---|---|
| Provider Enumeration Date | |
| Last Updated Date |
Provider Mailing Address Detail
| Address | |
|---|---|
| City | |
| State | () |
| Post Code | |
| Phone Number | |
| Fax Number |
Provider's Primary Taxonomy Detail
| Speciality | Specialist |
|---|---|
| Taxonomy | 174400000X |
| Licence No | 48706 |
|
Definition: An individual educated and trained in an applied knowledge discipline used in the performance of work at a level requiring knowledge and skills beyond or apart from that provided by a general education or liberal arts degree. |
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Provider's Other Legacy Identifiers
| Identifier | Identifier Type | Identifier State | Identifier Issuer |
|---|---|---|---|
| 20943 | MA | HEALTHNET PLAN PIN | |
| 42714479 | MA | UNITED HEALTHCARE PIN | |
| 10925 | MA | HN PIN | |
| 441041175 | MA | PALMETTO GBA RR PIN | |
| 776514 | MA | TU PIN | |
| 2872348-001 | MA | CIGNA PIN | |
| 42714479 | MA | FIRST HEALTH PIN | |
| 4588 | MA | MVP PIN | |
| I22280 | MA | BS PIN | |
| 156485 | MA | -- |
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